0000000000136772
AUTHOR
Thomas Kerz
Effect of intraarterial papaverine or nimodipine on vessel diameter in patients with cerebral vasospasm after subarachnoid hemorrhage.
Papaverine (P) and nimodipine (N) are the most widely used vasodilators when angiographic and symptomatic vasospasm is present after subarachnoid aneurysmatic hemorrhage (SAH). Their effect is only short-lived and no direct comparisons have been undertaken to evaluate the action of both substances directly. We retrospectively assessed the effect of either P or N on angiographic diameter reduction and capillary blood flow.Fifteen SAH patients with secured aneurysms and cerebral vasospasm received intraarterial P, fifteen similar patients received N. As the primary endpoint, pre- and post-infusion arterial diameters and capillary blood flow were rated retrospectively on angiographies and comp…
A case control study of statin and magnesium administration in patients after aneurysmal subarachnoid hemorrhage: incidence of delayed cerebral ischemia and mortality
To analyse the effect of the implementation of statin and magnesium treatment on delayed cerebral ischemia (DCI) and 14 day mortality in patients with subarachnoid hemorrhage (SAH).Retrospective, single-center, observational case control study. One hundred SAH patients received either simvastatin and magnesium, solely statin or no treatment.Eighteen percent (n=5) of patients receiving statin and magnesium treatment developed a DCI whereas 24% (n=5) in the statin group and 16% (n=8) in the control group had DCI. Dead by day 14 was registered in 18% (n=5) of patients in the statin and magnesium group, in 10% (n=2) in the statin group and in 27% (n=14) in the control group. None of the results…
Postoperative nausea and vomiting in patients after craniotomy: incidence and risk factors
Object The purpose of this study was to assess the incidence and risk factors of postoperative nausea and vomiting (PONV) after craniotomy because most available data about PONV in neurosurgical patients are retrospective in nature or derive from small prospective studies. Methods Postoperative nausea and vomiting was prospectively assessed within 24 hours after surgery in 229 patients requiring supratentorial or infratentorial craniotomy. To rule out the relevance of the neurosurgical procedure itself to the development of PONV, the observed incidence of vomiting was compared with the rate of vomiting predicted with a surgery-independent risk score (Apfel postoperative vomiting score). Re…
Anticoagulation in a Neurosurgical Patient with Heparin-Induced Thrombocytopenia Type II with Argatroban and Fondaparinux after Clipping of an Intracranial Aneurysm
Background: Therapeutic anticoagulation in patients after a major neurosurgical procedure remains critical because of the risk of a major intracranial bleed. Novel drugs could play
Early postoperative substitution procedure of the antioxidant ascorbic acid.
Postoperatively reduced concentration of ascorbic acid (AA) in plasma (or =45.5 micromol/l (or =800 microg/dl)) is commonly interpreted as increased metabolic requirements, but it is not shown yet that the patient benefits from a substitution toward normal levels of AA. This is due to the missing knowledge on how to substitute AA effectively to normal plasma values in postoperative patients. Therefore, a postoperative AA substitution procedure "overnight" to normal values in plasma was investigated on a postoperative intensive care unit (ICU) in a university hospital.Fifty-seven operated patients were randomly assigned to a control- or intervention group (CG and IG, respectively). In all pa…
Germany: Where Have We Been?
Germany’s health system organization is based on three major principles: compulsory insurance, compulsory contributions from both employers and employees and solidarity. A vast majority of German citizens follow the idea that health risks should be shared collectively by the community of all insured persons [9]. Irrespective of the amount each person had paid into the social system, all have access to comprehensive coverage. In order to understand Germany’s peculiarities in health policy, this chapter provides an introduction into Germany’s model of health care and then discusses which kinds of resource allocation strategies already have evolved. The second chapter deals with prospects for …
Anästhesie in der Neurochirurgie
Das Wort »Kraniotomie« subsumiert eine ganze Reihe von Interventionen, die von einem kleinen Bohrloch zur Evakuation eines chronischsubduralen Hamatoms oder dem Anbringen einer Drucksonde zur Uberwachung des intrakraniellen Drucks (ICP, »intracranial pressure«) uber eine osteoplastische Kraniotomie zur Entfernung einer Raumforderung (frontal, temporal, okzipital) bis zur Intervention in der hinteren Schadelgrube reichen konnen. Die Mehrzahl der neurochirurgischen Operationen ist mit einer aufwandigen Lagerung und erheblichen Kreislaufreaktionen verbunden. Die mogliche Ausdehnung des Eingriffs sollte vorab mit dem Operateur geklart sein, da Lagerung, Monitoring, Art und Grose der i.v.-Zugang…
Prospective assessment of postoperative pain after craniotomy.
Pain after craniotomy may be underdiagnosed, despite the fact that it can increase postoperative complications for example arterial hypertension and postoperative hemorrhage. This study investigates the incidence and intensity of pain after craniotomy and characterizes the influencing parameters. During a 1-year period 256 patients undergoing elective craniotomy were prospectively included in the study. Intensity of pain was evaluated 1, 4, and 24 hours after extubation using a verbal numerical rating scale (NRS) ranging from 0 (no pain) to 10 (maximal pain). Routine perioperative pain management was not influenced by the investigators. Parameters including patient-related factors, drug adm…
The Influence of Oxidative Stress on Neurological Outcomes in Spontaneous Intracerebral Hemorrhage
Spontaneous intracerebral hemorrhage (ICH) causes, besides the primary brain injury, a secondary brain injury (SBI), which is induced, amongst other things, by oxidative stress (OS) and inflammation, determining the patient’s outcome. This study aims to assess the impact of OS in plasma and cerebrospinal fluid (CSF) on clinical outcomes in patients with ICH. A total of 19 ICH (volume >
CT Angiography as a Confirmatory Test in Brain Death
Objective: From recent studies, it remains unclear whether CT angiography could be an alternative to other established ancillary tests for the diagnosis of brain death. We examined intracranial contrast enhancement in CT angiography after clinically established brain death and compared the results with EEG and TCD findings.
Contrast-enhanced transcranial Doppler ultrasonography in the diagnosis of brain death
The diagnosis of brain death (BD) is based on clinical criteria including deep coma, brain stem areflexia and apnoea. Depending on different local guidelines, confirmatory technical tests are sometimes mandatory.1 Since the 1990s, transcranial Doppler sonography (TCD) has found its place in these circumstances and fulfils most of the criteria of an ‘ideal test’ in confirming BD. To confirm intracranial circulatory arrest (CA) with Doppler sonography, typical flow patterns must be recorded in bilateral intracranial and extracranial brain-supplying arteries.2 A completely absent intracranial flow signal is not a reliable sign to determine CA because this can be due to transmission problems. I…
Zugangswege f�r die Medikamentenapplikation bei Herzkreislaufstillstand
Selecting a route for drug administration during CPR requires consideration of the speed with which access can be obtained, the technical difficulties involved in performing the procedure, the associated risk of complications, delays in drug delivery to the central circulation, and the duration of effective drug levels following injection. The peripheral venous route is the safest method, and drug delivery can be enhanced by a fluid bolus after injection of the medication. The circulation time is shortest after central venous injection, but there is some risk of complications. The femoral route is associated with a high incidence of unsuccessful catherization. The endotracheal tube provides…
Endovascular therapy for vasospasm after aneurysmatic subarachnoid hemorrhage
Balloon angioplasty and/or selective intra-arterial vasodilator therapies are treatment options in patients with vasospasm after subarachnoid hemorrhage (SAH). We analyzed the effect of balloon angioplasty and/or selective intra-arterial vasodilator therapy in our patients.Twenty-six patients (vasodilation group, VDT) were treated with intra-arterial nimodipine. The balloon angioplasty with nimodiopine-group (BAP-N group) comprised 21 patients. The primary endpoint of this study was successful angiographic vessel dilation in vasospastic vessels after balloon angioplasty, together with nimodipine (BAP-N group), compared to intra-arterial vasodilator therapy (VDT group) with nimodipine alone.…
Antagonizing dabigatran by idarucizumab in cases of ischemic stroke or intracranial hemorrhage in Germany—Updated series of 120 cases
Background Idarucizumab is a monoclonal antibody fragment with high affinity for dabigatran reversing its anticoagulant effects within minutes. Thereby, patients with acute ischemic stroke who are on dabigatran treatment may become eligible for thrombolysis with recombinant tissue-type plasminogen activator (rt-PA). In patients on dabigatran with intracerebral hemorrhage idarucizumab could prevent lesion growth. Aims To provide insights into the clinical use of idarucizumab in patients under effective dabigatran anticoagulation presenting with signs of acute ischemic stroke or intracranial hemorrhage. Methods Retrospective data collected from German neurological/neurosurgical departments ad…
Detection of intracranial circulatory arrest in brain death using cranial CT-angiography.
Background and purpose Computed tomographic-angiography (CT-A) is becoming more accepted in detecting intracranial circulatory arrest in brain death (BD). An international consensus about the use and the parameters of this technique is currently not established. We examined intracranial contrast enhancement in CT-A after clinically confirmed BD, compared the results with electroencephalography (EEG) and Transcranial Doppler Ultrasonography (TCD) findings and developed a commonly applicable CT-A protocol. Methods Prospective, monocentric study between April 2008 and October 2011. EEG, TCD and CT-A were performed in 63 patients aged between 18 and 88 years (mean, 55 years) who fulfilled clini…
Effects of Propofol on H-reflex in Humans
Background Depression of spinal cord motoneuron excitability has been proposed to contribute to surgical immobility. The H-reflex, which measures alpha-motoneuron excitability, is depressed by volatile anesthetics, whereas the action of propofol is unknown. The objective of this study was to determine the effects of propofol anesthesia on the H-reflex. Methods In 13 patients (group 1), H-reflex was measured before (T0), 3 min after (T1), and 10 min after (T2) a 2-mg/kg bolus dose of propofol, followed by an infusion of 10 mg x kg(-1) x h(-1). Ten patients (group 2) were studied when propofol was given via a programmable pump set to a propofol blood concentration of 6 microg/ml, and 10 pati…
Direct effects of Facio-Oral Tract Therapy® on swallowing frequency of non-tracheotomised patients with acute neurogenic dysphagia
Objectives: The aim of this study was to investigate the direct effect of Facio-Oral Tract Therapy ® on swallowing frequency of non-tracheotomised patients with acute neurogenic dysphagia. Methods: Within a pre-, post-/during and follow-up study design, 19 non-tracheotomised dysphagic patients were included consecutively and treated according to three specific preselected Facio-Oral Tract Therapy stimulation techniques. Results: The primary outcome was the direct effect of the three different Facio-Oral Tract Therapy stimulation techniques on the number of swallows. We found a significant effect of Facio-Oral Tract Therapy on swallowing frequency as compared to baseline with an increase by …
Germany: Where Are We Going?
Germany’s health policy, in the past, has tried to limit health expenditures by defining an overall health budget, by installing a DRG-system and by forcing patients to participate directly at health costs by demanding copayments. These measurements were somehow effective in keeping premiums stable but have led to resource allocation at the bedside and therefore on an implicit level. Yet, implicit-level decisions create ethical dilemmas for physicians as they not only have to deliver best medical care but shall also have cost in mind, are unjust because rationing criteria differ from one case to another, and create a general fear of legal uncertainty, in turn leading to defensive medicine w…
Intraoperative tramadol reduces shivering but not pain after remifentanil–isoflurane general anaesthesia. A placebo-controlled, double-blind trial
Background and objective Postoperative shivering and pain are frequent problems in patients recovering from anaesthesia with particularly high incidences being observed after remifentanil–isoflurane-based general anaesthesia. The opioid tramadol is generally effective in preventing shivering and treating pain, but its effects are not characterized after remifentanil-based general anaesthesia. This randomized, placebo-controlled, double-blind study evaluated the effects of intraoperative intravenous tramadol on postoperative shivering and pain after remifentanil-based general anaesthesia. Methods After Ethics Committee approval, 60 patients scheduled for lumbar disc surgery were included. Su…